NR674-Unit 6 Assignment – Clinical: SOAP Note

Unit 6 Assignment – Clinical: SOAP Note

Instructions

Each week students will choose one patient encounter to submit a Follow-up SOAP note for review.

Follow the rubric to develop your SOAP notes for this term.

The focus is on your ability to integrate your subjective and objective information gathering into formulation of diagnoses and development of patient-centered, evidence-based plans of care for patients of all ages with multiple, complex mental health conditions. At the end of this term, your SOAP notes will have demonstrated your knowledge of evidence-based practice, clinical expertise, and patient/family preferences as expected for an independent nurse practitioner incorporating psychotherapy into practice.

 

Rubric

NU674 Unit 6 Assignment – Clinical: SOAP Note

NU674 Unit 6 Assignment – Clinical: SOAP Note

CriteriaRatingsPts

This criterion is linked to a Learning OutcomeSubjective Information

3 pts

Level 5

Complete and concise summary of pertinent information.

2 pts

Level 3

Well organized; partial but accurate summary of pertinent information (>80%).

1 pts

Level 1

Poorly organized and/or limited summary of pertinent information (50%-80%); information other than “S” provided.

0 pts

Level 0

Less than 50% of pertinent information is addressed; or is grossly incomplete and/or inaccurate.

3 pts

This criterion is linked to a Learning OutcomeObjective Information

3 pts

Level 5

Complete and concise summary of pertinent information.

2 pts

Level 3

Partial but accurate summary of pertinent information (>80%).

1 pts

Level 1

Poorly organized and/or limited summary of pertinent information (50%-80%); information other than “O” provided.

0 pts

Level 0

Less than 50% of pertinent information is addressed; or is grossly incomplete and/or inaccurate.

3 pts

This criterion is linked to a Learning OutcomeAssessment: Problem Identification and Prioritization

3 pts

Level 5

Complete problem list generated and rationally prioritized; no extraneous information or issues listed.

2 pts

Level 3

Most problems are identified and rationally prioritized, including the “main” problem for the case (>80%).

1 pts

Level 1

Some problems are identified (50%-80%); incomplete or inappropriate problem prioritization; includes nonexistent problems or extraneous information included.

0 pts

Level 0

Less than 50% of problems are listed; or main problem missed; or problems not prioritized and/or identified nonexistent problems.

3 pts

This criterion is linked to a Learning OutcomeAssessment: Assessment of Current Psychiatric & Medical Condition(s) or Drug Therapy-related Problem

3 pts

Level 5

An optimal and thorough assessment is present for each problem.

2 pts

Level 3

An assessment is present for each problem listed but not optimal.

1 pts

Level 1

Assessment is present for 50-80% of problems

0 pts

Level 0

Less than 50% of problems include an appropriate assessment.

3 pts

This criterion is linked to a Learning OutcomeAssessment: Treatment Goals

3 pts

Level 5

Appropriate and relevant therapeutic goals for each identified problem.

2 pts

Level 3

Appropriate therapeutic goals for most identified problems (>80%).

1 pts

Level 1

Appropriate therapeutic goals for a few identified problems (50%-80%).

0 pts

Level 0

Less than 50% of problems have appropriate therapeutic goals.

3 pts

This criterion is linked to a Learning OutcomePlan: Treatment Plan

3 pts

Level 5

Specific, appropriate and justified recommendations (including drug name, strength, route, frequency, and duration of therapy) for each identified problem.

2 pts

Level 3

Mostly complete and appropriate for each identified problem (>80%).

1 pts

Level 1

Partially complete and/or inappropriate for a few identified problems (50%-80%); information other than “P” provided.

0 pts

Level 0

Less than 50% of problems have an appropriate and complete treatment plan.

3 pts

This criterion is linked to a Learning OutcomePlan: Counseling, Referral, Monitoring & Follow-up

2 pts

Level 5

Specific patient education points, monitoring parameters, follow-up plan and (where applicable) referral plan for each identified problem.

1 pts

Level 3

Patient education points, monitoring parameters, follow-up plan and referral plan (where applicable) for >80% of identified problems.

0.5 pts

Level 1

Patient education points, monitoring parameters, follow-up plan and referral plan (where applicable) for a few identified problems (50%-80%).

0 pts

Level 0

Less than 50% of problems include appropriate counseling, monitoring, referral and/or follow-up plan.

2 pts

Total Points: 20